Injection-drug-related infections (IDRIs) such as endocarditis have increased with the opioid epidemic. The infections tend to recur if the underlying addictions are not treated. Many health centers have improved outcomes in this population by forming an endocarditis team or a general IDRI team.  One tertiary health center in the southeastern region of the United States created an endocarditis team called iCARE to address a high recurrence and reoperation rate of 45% in this population, specifically for tricuspid valve replacements. Unique features of the team included a personalized addiction treatment plan for each patient, a post-acute discharge option with addiction management services, and perioperative buprenorphine dosing when appropriate. Before the team formed, there were zero patients initiated on buprenorphine pre-operatively and only 2% initiated at all while inpatient. After team formation, over 75% of patients were started on buprenorphine pre-operatively, which exceeded the goal of 60%. The median length of stay was reduced from 75 days to 30 days. Seven patients were successfully sent home with intravenous (IV) antibiotics, which saved a total of 166 inpatient days. Patients with IDRIs should be referred to health centers with a dedicated endocarditis team, with emphasis on addiction treatment and specific attention to healthcare access barriers.

Injection-drug related infections, Endocarditis team, iCARE, Antibiotics, Buprenorphine.

As the opioid crisis worsened over the past 20 years, the incidence of IDRIs has sharply increased. Deaths of young, previously healthy individuals from injection-related endocarditis have tripled since the turn of the 21^st century.[1] To successfully treat an IDRI, the underlying addiction must be treated. This brief review will describe how an interprofessional team addressed barriers to care in a vulnerable population of people who inject drugs (PWID) and improved outcomes in an academic hospital setting in the Southeastern United States.

Background
Endocarditis is an infection of the endocardial tissue and valve tissue in the heart. Pathogens in the bloodstream attach to heart tissue and reproduce to form vegetations, which can damage tissue and interfere with heart function. Etiology can be from foreign bodies such as dialysis catheters, from injection of drugs (usually opiates and/or stimulants), or from unknown causes.  Usually, the treatment is open heart surgery to remove the infected valve and implant an artificial valve, plus a prolonged course of IV antibiotics. The infection can be fatal depending on the pathogen, the severity of heart damage, which valves are involved, and the presence of comorbidities.

Significance
Management of endocarditis related to injection drug use is especially challenging because it can recur if the underlying addiction is not treated. The delivery of care in the form of valve replacement surgery is risky, with an estimated mortality rate of over 25%.[2] Surgery and post-surgical care in this population are also expensive, estimated to be over $350,000 per patient, which is then compounded if the infection recurs because of incomplete follow-up.[3]

Health care professionals describe many barriers to effective care of patients with injection-related infections, and patients describe significant discrimination affecting their care.[4] Barriers to treatment include limited access to addiction care, strict policies that require prolonged hospital stays, and stigmatizing attitudes within the health system.[5-7]

Context of addiction
Addiction is a serious medical condition that causes people to engage in risky and harmful behavior that is beyond their control. There are several misconceptions about addiction that affect patient care. For example, some surgeons believe addiction is a fatal disease and, therefore, treating an IDRI would be futile.[7] It is also often argued that addiction is a matter of personal moral failure, without considering the factors that exacerbate addiction, such as poverty, homelessness, and untreated mental health problems.[5]

One of the biggest misconceptions is the concept of abstinence or “detox” as a strategy to treat addiction. Because of withdrawal symptoms and previously misunderstood factors, abstinence tends to cause people to return to using drugs.[8] It is now widely accepted that harm reduction is more effective at treating substance use disorder than abstinence. Harm reduction is an evidence-based alternative approach focused on medication-assisted therapy (MAT) such as methadone or buprenorphine for opioid dependence, and various therapies for stimulant dependence. Providing sterile equipment in the community for people who continue to inject is an example of harm reduction.

Treatment dilemmas
Many surgeons are hesitant to operate on patients with injection-related infections because of the high risks of mortality and re-infection.  In recent years, a team approach has become the standard recommendation for the American Heart Association, the American College of Cardiology, and the European Society of Cardiology.[9,10] With the support of a dedicated team, surgeons may be more willing to operate.[7] Meta-analyses have described an increased likelihood of surgery and improved mortality rates when an endocarditis team supports the patient.[2]

iCARE team project
An academic medical center in the southeastern US formed the iCARE team (improving care for addiction-related endocarditis) in 2021. The iCARE team stemmed from a Quality Improvement project that was supported by the hospital with the goal of benefiting underserved populations. In this project, the population of PWID with IDRIs was underserved because addiction treatment was not equitably available to most patients coming from rural communities.  The team envisioned a pathway or “pipeline” that would support patients from diagnosis to discharge, with high-quality addiction treatment throughout the process and post-discharge.

Problem
The team first met to illustrate the process map of the current management as a visual aid to detect gaps in traditional care. For typical care, the average length of stay for people with IDRIs was 27 days because of delays in having surgery, delays in discharge, and difficulty coordinating 6 weeks of IV antibiotics. Despite the prolonged admissions, it became clear that addiction services had never been consulted for these patients, even though over 95% of the cases of tricuspid valve endocarditis were related to injection drug use. A staggering 45% percent of patients required a repeat of the same valve replacement surgery because of reinfection, most within the same year.

Interventions
The next step was to design a new process map for the ideal care pathway. Early Addiction medicine consult (also known as the IV drug use consult team) was a crucial step in the pathway. Through the Addiction team, a patient could be assigned to a peer support specialist, a trained substance use counsellor who was personally in addiction recovery, an addiction psychiatrist, and a personalized plan for beginning MAT could be designed. Concurrently, the infectious disease (ID) team would be consulted to begin antimicrobial planning and harm reduction strategies, such as screening for hepatitis and human immunodeficiency virus (HIV) and administering vaccinations when needed. Seeing these professionals would mean that a patient had effectively “enrolled” in the collaborative pathway.

The team convened formally once weekly to review patients and to informally check in as needed if surgical and/or discharge plans changed. An educational booklet was provided to the patient by a team member. The post-acute team was also involved in the weekly meetings to begin assessing the patient for possible ongoing admission to a hospitalist team with specific training in addiction medicine.  The ID team would evaluate each person for possible home IV antibiotics monitoring, which was a novel process at this hospital.  It was important to the team that, despite being called a pathway, each patient’s care was personalized and unique to their individual recovery journey.

An order panel was created to make sure all consults were formally placed, and all serologies/vaccines were ordered. A discharge summary template was specifically created for endocarditis patients with needle exchange program details for each person’s specific community/county. Narcan was prescribed to all patients taking opiates at discharge. Virtual visits with an Addiction professional were scheduled prior to discharge.

Over time, the team found that most hospital units were unaware of the iCARE team. An infographic was designed and displayed in units after verbal explanation to unit leadership. A one-click consult order to the Endocarditis Team was created in Epic with the ability to add and remove team members manually. Most referrals were coming from medical teams, medical ICUs, and Neuro ICUs, as patients often had advanced infections but were still able to begin the process of being enrolled in the project.

Novel approach to perioperative pain control
During the project implementation period, most literature was still supporting cessation of buprenorphine pre-operatively to avoid complications with anesthesia, and practice patterns in the community aligned with this misconception.  However, stopping buprenorphine requires a re-induction phase over several days of microdosing that can precipitate opiate withdrawal. The iCARE team was able to safely and effectively start or continue buprenorphine pre-operatively, consistent with evidence from older case studies.[11]

The iCARE peri-operative protocol included:

• Continuing buprenorphine/methadone pre-op, including on the day of surgery (12mg), and immediately post-op.
• Performing erector spinae block by an anesthesiologist.
• Administering pre-op pregabalin and acetaminophen.
• Administering pre-op fentanyl bolus, ketamine bolus, then sufentanil infusion and ketamine infusion.
• Continuing post-op buprenorphine and ketamine infusions, plus scheduled gabapentin, acetaminophen, and lidocaine patches.

The outcomes were impressive. Twenty-five patients were enrolled within the 6-month period. Before the team formed, there were zero patients initiated on buprenorphine pre-operatively and only 2% initiated at all while inpatient. After team formation, over 75% of patients were started on buprenorphine pre-operatively, which exceeded the goal of 60%. Median length of stay decreased from 75 days to 30 days. Seven patients were successfully sent home with IV antibiotics, which saved a total of 166 inpatient days.

Readmission rates were lower for patients who followed up with the original inpatient addiction team compared to other types of follow-up (10% at 30 days vs 26%; 19% at 60 days vs 39%; 27% at 90 days vs 50%). For patients sent home with home infusion, 100% returned to the ID clinic as scheduled, and only one person was readmitted within 30 days (14%).

Implications
The same improvement in outcomes can be expected in other populations of people with invasive drug-related infections (osteomyelitis, spine and central nervous system infections, septic arthritis, mycotic aneurysms, etc). Even when surgery is contraindicated, there are several points of intervention to improve care. The role of the nurse on these teams is significant because their experience and education prepare them to focus on outcomes and quality improvement projects. Nurses tend to spend the most time with the patient and family; thus, as a team member, they bring insight about how to individualize the person’s care.[12]

Recommendations
When forming a team to improve care for a vulnerable population, the experiences of that population should be studied. Clearly, stigma negatively affects the experiences of people who inject drugs, but there are some simple ways to use less stigmatizing language. For example, the term intravenous drug user (IVDU) is depersonalizing, and one could consider using PWID. Avoid labelling a person as a “user” or an “addict.”  A person who is no longer using drugs can be described exactly, instead of using the term “clean.” Leaving against medical advice can be reframed as “patient-directed discharge” to reflect that people have a right to take care of their own families and finances even while being treated for a medical condition.[13]

Health care centers hoping to improve care for injection-related endocarditis may wish to explore expanded access to buprenorphine that was included in coronavirus disease (COVID) relief legislation. Telemedicine may be used to improve access to specialists during and after hospitalization. Smaller hospitals may consider transferring patients promptly to a center with an endocarditis team.  Formation of patient advisory panels is recommended for ongoing qualitative research into the lived experience of patients with IDRI.[14]

Numerous endocarditis teams have formed in the past 5-10 years with similar outcomes reflecting reduced mortality, reduced length of stay, and reduced readmissions. Attitudes are shifting toward management of addiction as a chronic illness and not a crime. An infection episode, if detected early enough, can jumpstart a person’s recovery process.

I would like to thank Clare Mock, MD, CPPS, and Asher Schranz, MD, MPH, for their creation of the original iCARE team.

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Megan Quinn
Department of Neurosurgery
University of North Carolina, Chapel Hill, United States
Email: quinnfnp@gmail.com

The author contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles and was involved in writing—original draft preparation and writing—review & editing to refine the manuscript.

Not applicable

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https://doi.org/10.63096/medtigo3092236

Quinn M. Improving care for addiction-related endocarditis. medtigo J Emerg Med. 2025;2(3):e3092236. doi:10.63096/medtigo3092236 Crossref